Review
Diabetes self-management in patients with low health literacy: Ordering findings from literature in a health literacy framework

https://doi.org/10.1016/j.pec.2011.11.015Get rights and content

Abstract

Objective

To review studies on the association between health literacy (HL), diabetes self-management and possible mediating variables.

Methods

We systematically searched for empirical studies in PubMed. Findings were ordered by a HL framework that outlines routes between HL, sociocognitive determinants and health actions.

Results

Of the 11 relevant studies, three reported a significant positive association between HL and specific diabetes self-management domains. Ten studies investigated the association between HL and knowledge (n = 8), beliefs (n = 2), self-efficacy (n = 3) and/or social support (n = 1). Significant associations were found between HL and knowledge (n = 6), self-efficacy (n = 1) and social support (n = 1). Of the three studies evaluating the effect of these sociocognitive variables on diabetes self-management, only one found proof for a mediating variable (social support) in the pathway between HL and self-management.

Conclusion

There is only limited evidence for a significant association between HL and diabetes self-management, and for the mediating role of sociocognitive variables in this pathway.

Practice implications

Longitudinal studies, including HL, diabetes self-management and potential mediators, are needed to substantiate possible associations between these variables. Such research is essential to enable evidence-based development of interventions to increase adequate and sustainable self-management in diabetic patients with low HL.

Introduction

Self-management has become increasingly important in the treatment of diabetes mellitus type 2 (DM2). Patients with DM2 have become partners in the treatment of their own disease and self-management is crucial to obtain adequate glycaemic control. There is no universally accepted definition of self-management. Barlow et al. defined general self-management as the patient's ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic disease [1]. Diabetes self-management is generally divided into four domains: nutritional management; exercise and physical activity; blood glucose monitoring; and medication utilization [2], [3], [4]. The American Association of Diabetes Educators (ADEE) operationalized nutritional management into making healthy food choices, understanding portion sizes and learning the best times to eat. Regular activity is important for overall fitness, weight management and blood glucose control. Together with healthcare professionals, patients should address barriers to regular physical activity and develop an appropriate plan to balance food and medication with the activity level. The AADE also note that daily self-monitoring of blood glucose provides patients with diabetes the information they need to assess how food, physical activity and medications affect their blood glucose levels. To adequately utilize medications, patients should be knowledgeable about each medication, including its action, side effects, efficacy, toxicity, prescribed dosage, appropriate timing, frequency of administration, effect of missed/delayed doses and instructions for storage, travel and safety [5].

To implement optimal diabetes self-management, patients must apply specific knowledge and decision-making skills across the multiple domains of self-management. This requires adequate health literacy (HL). The Institute of Medicine (IOM) defined HL as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions [6]. Subjects with low HL tend to be less likely to successfully manage chronic diseases [7], [8]. They generally have less knowledge about their disease, exhibit inadequate self-management and have poor health outcomes [9], [10], [11], [12], [13], [14].

In 2007 Paasche-Orlow and Wolf developed a framework that outlined routes through which HL might affect health actions in the access and utilization of health care, patient–provider interactions and self-management [15]. Drawing upon these ideas, von Wagner et al. developed a framework for health literacy and health actions that was derived from health psychology (Fig. 1) [16]. This framework was developed to guide research on the processes through which HL affects health outcomes. The framework proposes that health actions (access and use of health care, patient–provider interactions, and the management of health and illness, e.g. diabetes self-management) determine health outcomes (e.g. HbA1c level) through sociocognitive motivational and volitional determinants. Motivational determinants include traditional social cognition constructs (e.g. beliefs and attitudes) which in turn are associated with access to health information and knowledge. For example, adequate knowledge in diabetes self-management consists of knowing the effect of food on blood glucose. Volitional determinants on the other hand refer to objective and subjective (e.g. self-efficacy) action control and include task-specific skills, such as information processing and navigational skills to acquire specific knowledge about adherence regimens, and cognitive skills (e.g. anticipate on glucose levels). The motivational and volitional determinants are not affected by levels of HL alone, but form a symbiotic relationship with external system factors. For example accessibility of health care information, communication skills of the health care provider, and out-of-pocket costs for health care. The motivational determinant ‘patient's understanding of a healthy diet’ also depends on how well the healthcare provider is able to explain what the patient should or should not eat to maintain a healthy diet [16].

The aim of this paper is to review the literature on the association between HL and diabetes self-management, and the possible mediating variables in this pathway. A secondary aim is to order the findings in the framework proposed by von Wagner et al. In the Section 2 we explain why we chose this framework to order our literature findings and describe the methods for our literature review. The findings of our literature review are schematically reported in the Section 3. The paper ends with a discussion of the findings and implications for further research.

Section snippets

Literature review

In July 2011, we searched for articles on HL, diabetes, diabetes self-management and its four domains (nutritional management; exercise and physical activity; blood glucose monitoring; and medication utilization). Relevant search terms were derived from literature on HL and diabetes self-management [9], [10], [11], [12], [13], [14]. We used the following keywords and Medical Subject Headings (MeSH) to search in PubMed:

[Health literacy or literacy or numeracy] and [diabetes] and [self-management

Results

In this section we first summarize the content and methodological quality of the papers that were included in our review (Section 3.1). We then describe findings on the association between HL and diabetes self-management (Section 3.2). We end with findings on possible mediating variables in the association between health literacy and self-management, divided into motivational and volitional determinants (Section 3.3). Fig. 3 presents a schematic ordering of the findings in von Wagner's

Discussion and conclusion

Below we discuss the main findings in this literature review and describe various gaps in research on HL and diabetes self-management. The discussion ends with a reflection on strengths and weaknesses of this study. The discussion is followed by a general conclusion and implications for further research.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgements

The authors thank Petra Jellema for her constructive comments on this review.

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